Healthcare Provider Details

I. General information

NPI: 1336518166
Provider Name (Legal Business Name): PHEONIX HEALTHCARE CONSULTANTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2015
Last Update Date: 11/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 WALLROCK CT
OCOEE FL
34761-4457
US

IV. Provider business mailing address

256 WALLROCK CT
OCOEE FL
34761-4457
US

V. Phone/Fax

Practice location:
  • Phone: 407-770-7026
  • Fax: 407-703-2721
Mailing address:
  • Phone: 407-770-7026
  • Fax: 407-703-2721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11477
License Number StateFL

VIII. Authorized Official

Name: DERRICK OMAR STEPHENS
Title or Position: PRESIDENT AND CEO
Credential: LCSW
Phone: 407-770-7026